Common use of Grievance Administration Clause in Contracts

Grievance Administration. Internal (plan level) Grievance An Enrollee may file an Internal Enrollee Grievance at any time with the One Care Plan or its providers by calling or writing to the Contractor or provider. The Contractor must have a system in place for addressing Enrollee Grievances, including Grievances regarding reasonable accommodations and access to services under the Americans with Disabilities Act. The Contractor must maintain written records of all Grievance activities, and notify CMS and EOHHS of all internal Grievances. The system must meet the following standards: Timely acknowledgement of receipt of each Enrollee Grievance; Timely review of each Enrollee Grievance; Response, electronically, orally or in writing, to each Enrollee Grievance within a reasonable time, but no later than thirty (30) days after the Contractor receives the Grievance; The Contractor may extend the thirty (30) day timeframe for processing a Grievance by up to fourteen (14) calendar days if the Enrollee requests the extension or if the Contractor shows there is a need for additional information and how the delay is in the interest of the Enrollee. If the Contractor extends the timeframe for a Grievance and it is not at the Enrollee’s request, the Contractor must make reasonable efforts to give the Enrollee prompt oral Notice of the delay. In addition, within two (2) days the Contractor must give the Enrollee written Notice of the reason for the extended timeframe and inform the Enrollee of the right to file a Grievance if he or she disagrees with that decision. Expedited response, orally or in writing, within twenty‑four (24) hours after the Contractor receives the Grievance to each Enrollee Grievance whenever Contractor extends the Appeals timeframe or Contractor refuses to grant a request for an expedited Appeal; Provides notice to the Enrollee of the disposition of the Grievance meets the requirements of 42 C.F.R § 438.10 and: Be produced in a manner, format, and language that can be easily understood; Be made available in Prevalent Languages, upon request; and Include information, in the most commonly used languages about how to request translation services and Alternative Formats; and The availability to Enrollees of information about Enrollee Grievances and Appeals, as described here and in Section 2.12, including reasonable assistance in completing any forms or other procedural steps, which shall include interpreter services and toll‑free numbers with TTY/TDD and interpreter capability; and. Ensure that the individuals who make decisions on Grievances are individuals who: Were neither involved in any previous level of review or decision‑making nor are a subordinate of any such individual; and If deciding any of the following, are individuals who have the appropriate clinical expertise, as determined by EOHHS, in treating the Enrollee’s condition or disease: A Grievance regarding denial of expedited resolution of an Appeal; and A Grievance that involves clinical issues. Takes into account all comments, documents, records, and other information submitted by the Enrollee or the Appeal Representative without regard to whether such information was submitted or considered in the initial Adverse Benefit Determination. A Grievance record‑keeping system that includes include the name of the covered person for whom the Grievance was filed; a general description of the reason for the grievance; the date received; the date of each review or, if applicable, review meeting; and resolution information including date of resolution. The Grievance record must be accessible to CMS and EOHHS upon request.